A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

Observe for signs of infection

Examine the skin for generalized urticaria

Review laboratory test results for low hemoglobin

Monitor the mouth for signs of xerostomia

Answer and Explanation

The Correct Answer is A

Radiation therapy can cause immunosuppression, which increases the risk of infection. The nurse should monitor the client for signs of infection such as fever, chills, malaise, or purulent drainage.

Examine the skin for generalized urticaria. This is not a common side eﬀect of radiation therapy, as urticaria is an allergic reaction that causes hives or welts on the skin. Radiation therapy can cause localized skin irritation, erythema, or dryness, but not generalized urticaria.
Review laboratory test results for low hemoglobin. This is not a direct eﬀect of radiation therapy, as hemoglobin is a component of red blood cells that carries oxygen in the blood. Radiation therapy can cause anemia, which is a low number of red blood cells, but not necessarily low hemoglobin.
Monitor the mouth for signs of xerostomia. This is not relevant for a client who receives radiation therapy to treat lung cancer, as xerostomia is dry mouth caused by reduced salivary gland function. This can occur in clients who receive radiation therapy to treat head and neck cancer, but not lung cancer.

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Correct Answer is ["B","C","E"]

Explanation

These actions help to control bleeding, reduce blood pressure, and promote clotting.

a. Tilt the client's head backward. This is not recommended, as it can cause blood to drain into the throat and increase the risk of aspiration, nausea, or vomiting.

d. Instruct the client to blow his nose. This is not advisable, as it can dislodge any clots that have formed and worsen bleeding.

A. The medication will prevent wheezing. B. The medication will decrease coughing episodes. C. The medication will reduce inﬂammation. D. The medication will open the airways. E. The medication will stimulate ﬂow of mucus.

Correct Answer is ["A","D"]

Explanation

These responses are correct and explain how albuterol helps the client's breathing. Albuterol is a short- acting beta2-agonist that causes bronchodilation and relieves bronchospasm, which are the main causes of wheezing and dyspnea in clients who have asthma or COPD. By opening the airways, albuterol improves gas exchange and oxygenation.

b) The medication will decrease coughing episodes. This response is incorrect and does not explain how albuterol helps the client's breathing. Albuterol does not have a direct eﬀect on coughing, which is a reﬂex response to irritation or obstruction of the airways. Coughing may be beneficial for clearing secretions and mucus from the lungs, but it may also cause bronchoconstriction and inﬂammation. The nurse should advise the client to use other measures to decrease coughing, such as drinking ﬂuids, using a humidifier, or taking an expectorant.
c) The medication will reduce inﬂammation. This response is incorrect and does not explain how albuterol helps the client's breathing. Albuterol does not have an anti-inﬂammatory eﬀect on the airways, which are often inﬂamed and swollen in clients who have asthma or COPD. Inﬂammation can contribute to airway obstruction and mucus production, which impair gas exchange and oxygenation. The nurse should inform the client that albuterol is used for quick relief of acute symptoms, but not for long-term control or prevention of inﬂammation. The client may need to use another medication, such as an inhaled corticosteroid, to reduce inﬂammation.
e) The medication will stimulate ﬂow of mucus. This response is incorrect and does not explain how albuterol helps the client's breathing. Albuterol does not have a direct eﬀect on mucus production or clearance, which are often increased in clients who have asthma or COPD. Mucus can cause airway obstruction and infection, which impair gas exchange and oxygenation. The nurse should advise the client to use other measures to stimulate ﬂow of mucus, such as drinking ﬂuids, using a humidifier, or taking an expectorant.

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A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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